'We're At Our Breaking Point'

Plenty such people poured into Grady on Saturday night. Just before 2 a.m., about when the hospital was considering going on trauma diversion, the waiting room was choked with some 50 patients and another 30-odd relatives and friends. Many slumped in their seats, staring despondently at the blaring TV sets. Others paced anxiously, accosting anyone with an air of authority. One woman who had just spoken to a nurse reported back to her family, "They've got a lot of trauma back there and it's going slow." Wait times at Grady regularly reach eight hours and can sometimes stretch to 12 hours or more. A growing number of patients give up long before then. According to hospital figures, walkouts increased from around 8 percent of patients in 2001 to about 12 percent in 2006.

Alexis Carter was nearly in that group. That Saturday, she arrived at the ER at 4 p.m. with pelvic pain and bleeding (she had started a new job and her insurance hadn't yet kicked in). Hours later, as her pain grew unbearable, she retrieved some Ibuprofen from her car to try to relieve it. Around midnight, Carter's mother, who had been calling to check on her, blew in like a tempest. She marched up to the nurses' station, pitched a fit and demanded that her daughter be treated. Nothing happened. At 3 a.m., a sympathetic nurse practically smuggled Carter back to the triage area, leapfrogging her over other patients. When Carter reached the Blue Zone, she received a bed in the hallway—and waited some more. Finally, at 5 a.m., 13 hours after she arrived at Grady, a doctor came to examine her. "I just think it's crazy you could leave people waiting that long," said Carter. "It's pathetic."

In an attempt to speed things up, Grady has introduced a number of reforms. Three years ago, using grant money from the Robert Wood Johnson Foundation, it created the Care Management Unit, a seven-bed annex aimed at treating patients with ailments like diabetes and congestive heart failure who might otherwise be admitted to the hospital. Then, on the eighth floor, Grady took over some unused space to set up the 17-bed Care Initiation Unit, designed to pull admitted patients out of the ER and start their lab work and feeding while they wait for a bed to open up. And just off the waiting room below, the hospital established a fast-track section staffed by physician assistants and nurse practitioners to treat mild conditions like cuts and coughs.

As much as that might facilitate patient flow, however, the bottleneck remains. Last year, Grady spent 3,600 hours on some form of diversion, compared to 1,400 hours in 2001. Other hospitals are increasingly diverting patients as well, though Kellerman carps that their standards are sometimes questionable. Some will go on what they term "case by case" trauma diversion. "That term drives me crazy," said Kellerman, who speculates that it's a way for the hospital to conduct what's known as a "wallet biopsy"—accepting paying patients while rejecting nonpaying ones. Whatever the reason, the bottom line is, if everyone else is turning a patient away, chances are he'll wind up at Grady.

Few experience the stress of diversion more directly than the paramedics charged with rushing patients to treatment. Scott Cathcart, a Grady EMS supervisor, said it's common for an ambulance to be forced to bypass a closer hospital because it's on diversion. He recalled the case of an 8-year-old hit by a car who was turned away from two ERs before arriving 20 minutes later at a third that could take her. Often, as soon as one hospital begins diverting ambulances, others quickly follow suit. In which case, "we've got a rule," said Cathcart. "Once all are on diversion, none are on diversion." (By federal law, an ER must accept a patient brought to its doors.)

At 4:30 a.m., an hour after Grady went on trauma diversion, Kellerman took a phone call. A doctor from Chestatee Regional Hospital in Dahlonega, Ga., a mountain town 70 miles north of Atlanta, wanted to transfer a patient who needed more sophisticated care than his medical center could offer. The patient, who was in a vehicle crash, had a fractured femur and possibly a brain injury. Unlike some other states, Georgia lacks a coordinated statewide trauma system to help distribute patients to the appropriate facility. That leaves physicians to shop patients around themselves. Though the Chestatee doctor had contacted North Fulton Regional Hospital in Roswell, Ga.—which was closer to Dahlonega—he told Kellerman that an ER doctor there had hung up on him. Kellerman sympathized, but explained that one of Grady's CT scans was down. "I'll make a deal with you," he said. "Let me talk to my trauma surgeon. But could you try North Fulton again? They're not listed as being on diversion."